HHS Defines “Essential Health Benefits”

Under PPACA, the Department of Health and Human Services (HHS) has issued two sets of proposed regulations that will impact the design and availability of health care plans. Some of the highlights include:

10 Benefits That Must Be Covered

New regulations extend the rules to all non-grandfathered plans offered in the individual and small group markets (generally less than 100 employees).

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance abuse disorder services
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

Cost-Sharing Limits

According to the regulations, the limit on cost-sharing, including deductibles, co-payments, co-insurance and employee charges, will be set at $6,250 for self-only coverage in 2013 and $12,500 for other tiers. The regulations also say that in 2014, deductibles may not exceed $2,000 for individual coverage and $4,000 for other tiers.

Calculating Minimum Value

In order for employers with at least 50 full-time employees to satisfy the employer mandate, they must cover at least 60% of the total cost of the health care plan. In a Minimum Value (MV) calculator, which will be available on the HHS website, assumptions will be based on a standard population of participants in self-funded group health plans rather than plans available in individual and small group markets. Employers with self-funded plans will need to follow the rules on MV calculations for purposes of complying with the employer mandate.

To view other articles from the SIP Winter Newsletter, please click here.

In cooperation with NAEBA

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